INFORMATION REQUEST FORM

To receive a brochure and enrollment form for the AMRA TRICARE supplement program, write ASI at
P.O. Box 2510
Rockville, Md 20847
Or call toll-free at 1-800-638-2610.

For faster service, you can use the online form below to reach us by e-mail with all the appropriate information.

Contact Information 
            Name: 
  E-mail Address: 
  Address Line 1: 
  Address Line 2: 
            City: 
           State:     Zip: 
    Phone Number: 
        Your age:
Please indicate your status:
Active Duty       Retiree

Please tell us what information you are interested in receiving:
I'm not enrolled in Tricare Prime. Send me information about your Tricare Standard/Extra supplement plan.
I'm enrolled in Tricare Prime. Send me information about your TRICARE PRIME supplement plan.
(not available to dependents of active duty members)

I learned about the AMRA Tricare Supplement program from the following website. Check one:
www.amratricare.com  Other

    

This program may not be available to residents of all states. You will be notified by the Administrator if you are ineligible for coverage.

[ TRICARE PLAN OPTIONS | SUPPLEMENTAL PLAN OPTIONS ]

[ WHAT THE SUPPLEMENTAL PLAN PAYS / PREMIUMS ]

[ DOWNLOAD ENROLLMENT FORM AND AMRA MEMBERSHIP APPLICATION TO APPLY ]

[ DOWNLOAD STATEMENT OF CLAIM FORM APPLICATION ]

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